Provider Demographics
NPI:1346552288
Name:DIETZ, BRIAN E (OD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:E
Last Name:DIETZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2765 FORT AMANDA RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-4813
Mailing Address - Country:US
Mailing Address - Phone:419-228-3937
Mailing Address - Fax:419-228-3939
Practice Address - Street 1:2765 FORT AMANDA RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-4813
Practice Address - Country:US
Practice Address - Phone:419-228-3937
Practice Address - Fax:419-228-3939
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5938/T2853152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist